Unit 9:  Comparative Unit 9:  Comparative Psychotherapies - Psychotherapies - SeminarSeminar            

This week we read chapters 16 This week we read chapters 16 and and Read the following article on Read the following article on Strategic Family Therapy:Strategic Family Therapy:

National Institute on Drug Addiction (NIDA) (n.d.)National Institute on Drug Addiction (NIDA) (n.d.)

Brief strategic family therapy for adolescent drug Brief strategic family therapy for adolescent drug abuse.abuse.

Read Chapter 1 � Brief Strategic Family Therapy: Read Chapter 1 � Brief Strategic Family Therapy: An overview Retrieved 08/12/2008 fromAn overview Retrieved 08/12/2008 from

http://www.drugabuse.gov/txmanuals/bsft/BSFTIndex.htmlhttp://www.drugabuse.gov/txmanuals/bsft/BSFTIndex.html

Unit 9:  Comparative Unit 9:  Comparative Psychotherapies - Psychotherapies - SeminarSeminar            

Read article on principles of drug addiction Read article on principles of drug addiction treatment:treatment:

National Institute on Drug Addiction (NIDA) (n.d.)National Institute on Drug Addiction (NIDA) (n.d.)

Principles of drug addiction treatment: A research Principles of drug addiction treatment: A research based guidebased guide

Read the first article, �Principles of effective Read the first article, �Principles of effective treatment.�  treatment.� 

Retrieved 08/12/2008 fromRetrieved 08/12/2008 from

http://www.nida.nih.gov/podat/PODATIndex.htmlhttp://www.nida.nih.gov/podat/PODATIndex.html

Unit 9:  Comparative Unit 9:  Comparative Psychotherapies - Psychotherapies - SeminarSeminar            

Read Article on Dual Diagnosis:Read Article on Dual Diagnosis:

Leshner, A. I.  (1999)  Drug abuse and mental Leshner, A. I.  (1999)  Drug abuse and mental disorders: Co-morbidity is realitydisorders: Co-morbidity is reality

NIDA Notes, Vol. 14NIDA Notes, Vol. 14, �Directors' Column�.  , �Directors' Column�.  Retrieved 08/12/2008 fromRetrieved 08/12/2008 from

http://www.drugabuse.gov/NIDA_Notes/http://www.drugabuse.gov/NIDA_Notes/NNVol14N4/DirRepVol14N4.htmlNNVol14N4/DirRepVol14N4.html

Discussion Question 1Discussion Question 1

1.  Treatment for addictions is most 1.  Treatment for addictions is most often done in a group setting.  Why do often done in a group setting.  Why do you think this is so?  What in the you think this is so?  What in the nature of addictive personality or nature of addictive personality or addition problems makes group addition problems makes group therapy a more effective treatment therapy a more effective treatment venue?? venue??

Discussion Question 2Discussion Question 2

2.  Strategic Family Therapy (SFT):  2.  Strategic Family Therapy (SFT):  According to the theory of SFT, what is According to the theory of SFT, what is the cause of the dysfunctional the cause of the dysfunctional behavior?  What are the other behavior?  What are the other fundamental assumptions of SFT fundamental assumptions of SFT treatment?  treatment?  

Discussion Question 3Discussion Question 3

3.  Dual Diagnosis:  If your client has 3.  Dual Diagnosis:  If your client has both an addiction and a psychiatric both an addiction and a psychiatric problem such as depression or bipolar problem such as depression or bipolar disorder, which do you treat first?  Or disorder, which do you treat first?  Or should you treat them both at the should you treat them both at the same time?  Why?  What if the client is same time?  Why?  What if the client is just trying to treat their psychiatric just trying to treat their psychiatric problem with the drug/alcohol? problem with the drug/alcohol?

Group and Family Group and Family TherapyTherapy Group therapy and family therapy Group therapy and family therapy

both feature multiple clients both feature multiple clients being treated togetherbeing treated together

However, they are quite distinct However, they are quite distinct from each other, with separate from each other, with separate histories and methodshistories and methods

We will consider them separately We will consider them separately in this chapterin this chapter

Group Therapy: An Group Therapy: An Interpersonal Interpersonal EmphasisEmphasis Most forms of group therapy strongly Most forms of group therapy strongly

emphasize interpersonal interactionemphasize interpersonal interaction– take advantage of the fact that the group take advantage of the fact that the group

therapy experience itself is based on therapy experience itself is based on interacting with other people interacting with other people

– Irvin Yalom is a leader in this interpersonal Irvin Yalom is a leader in this interpersonal approach to group therapyapproach to group therapy

Clients’ problems stem from flawed Clients’ problems stem from flawed interpersonal relationship skillsinterpersonal relationship skills

If they can practice and improve on this with If they can practice and improve on this with fellow group members, they can generalize fellow group members, they can generalize lessons learnedlessons learned

Therapeutic Factors in Therapeutic Factors in Group TherapyGroup Therapy UniversalityUniversality

– Clients realize that others share the same Clients realize that others share the same struggles (“we’re all in the same boat”)struggles (“we’re all in the same boat”)

Especially powerful in homogeneous groupsEspecially powerful in homogeneous groups

Group CohesivenessGroup Cohesiveness– Feelings of interconnectedness among Feelings of interconnectedness among

group membersgroup members– Trust, acceptance, belongingnessTrust, acceptance, belongingness– Analogous to therapeutic alliance in Analogous to therapeutic alliance in

individual therapy individual therapy

Therapeutic Factors in Therapeutic Factors in Group Therapy (cont.)Group Therapy (cont.) Interpersonal LearningInterpersonal Learning

– The same interpersonal tendencies that The same interpersonal tendencies that contributed to the client’s problems will contributed to the client’s problems will appear in the group contextappear in the group context

– Group members form relationships with Group members form relationships with each other and work to improve them, each other and work to improve them, and those improvements will help with and those improvements will help with outside relationships eventuallyoutside relationships eventually

Therapeutic Factors in Therapeutic Factors in Group Therapy (cont.)Group Therapy (cont.) Interpersonal Learning (cont.)Interpersonal Learning (cont.)

– The group becomes a social microcosm for The group becomes a social microcosm for each clienteach client

Clients enact their own relationship pathology Clients enact their own relationship pathology (without knowing it) in the group itself(without knowing it) in the group itself

– Focus on the here-and-nowFocus on the here-and-now Discourage discussion of lives outside of Discourage discussion of lives outside of

therapytherapy Encourage discussion of relationships between Encourage discussion of relationships between

group members in the current momentgroup members in the current moment Clients talk directly with each other about they Clients talk directly with each other about they

way they behave toward each otherway they behave toward each other

Discussion QuestionDiscussion Question

What are some potential ethical What are some potential ethical dilemmas of group therapy? For dilemmas of group therapy? For instance, what steps, if any, should be instance, what steps, if any, should be taken by a clinical psychologist if two taken by a clinical psychologist if two group therapy clients begin dating? group therapy clients begin dating? Additionally, how can a psychologist Additionally, how can a psychologist ensure confidentiality in a group setting? ensure confidentiality in a group setting?

Is confidentiality in a group setting Is confidentiality in a group setting possible?possible?

Practical Issues in Practical Issues in Group TherapyGroup Therapy Group membershipGroup membership

– Typically 5-10 clientsTypically 5-10 clients– Open-enrollment groups—individuals leave Open-enrollment groups—individuals leave

or join at any timeor join at any time– Closed-enrollment groups—members start Closed-enrollment groups—members start

and finish togetherand finish together– Most individuals can be included, unless Most individuals can be included, unless

they can’t interact meaningfully with they can’t interact meaningfully with others and reflect upon that interactionothers and reflect upon that interaction

Psychosis, acute crisis, frequent absences are Psychosis, acute crisis, frequent absences are problematicproblematic

Practical Issues in Practical Issues in Group Therapy (cont.)Group Therapy (cont.) Preparing clients for group Preparing clients for group

therapytherapy– Correct misconceptionsCorrect misconceptions– Provide realistic and encouraging Provide realistic and encouraging

data about outcomedata about outcome– Encourage helpful ways of Encourage helpful ways of

participatingparticipating

Practical Issues in Practical Issues in Group Therapy (cont.)Group Therapy (cont.) Developmental Stages of Therapy Developmental Stages of Therapy

GroupsGroups– Initially, cautious and concerned Initially, cautious and concerned

about acceptanceabout acceptance– Next, some jockeying for position in Next, some jockeying for position in

the social “pecking order”the social “pecking order”– Finally, cohesiveness emergesFinally, cohesiveness emerges

Practical Issues in Practical Issues in Group Therapy (cont.)Group Therapy (cont.) CotherapistsCotherapists

– Often, group therapy is conducted by a Often, group therapy is conducted by a team of two therapists (rather than one)team of two therapists (rather than one)

– Second set of eyes and ears can attend to Second set of eyes and ears can attend to client behaviorsclient behaviors

– Also, therapists can model healthy Also, therapists can model healthy interactioninteraction

– Cotherapy can be problematic when Cotherapy can be problematic when therapists are competitive, distrustful, or therapists are competitive, distrustful, or have incompatible therapy orientationshave incompatible therapy orientations

Practical Issues in Practical Issues in Group Therapy (cont.)Group Therapy (cont.) Socializing between clientsSocializing between clients

– Extra-group socializing between Extra-group socializing between clients (romantic or platonic) is a clients (romantic or platonic) is a significant problemssignificant problems

– Even when prohibited at the outset, it Even when prohibited at the outset, it happens at timeshappens at times

– Loyalty to friendship may exceed Loyalty to friendship may exceed loyalty to grouployalty to group

– Other group members can feel Other group members can feel excludedexcluded

Discussion QuestionDiscussion Question

Are closed- and open-enrollment Are closed- and open-enrollment groups better suited for certain types groups better suited for certain types of psychological disorders? Are of psychological disorders? Are heterogeneous and homogeneous heterogeneous and homogeneous groups better suited for certain types groups better suited for certain types of psychological disorders? of psychological disorders?

Do you think that the composition of a Do you think that the composition of a group contributes to therapy group contributes to therapy effectiveness? Explain your responses.effectiveness? Explain your responses.

Ethical Issues in Group Ethical Issues in Group TherapyTherapy ConfidentialityConfidentiality

– Clients should maintain confidentiality of Clients should maintain confidentiality of fellow members, but difficult to enforcefellow members, but difficult to enforce

– Consequences of broken confidentiality Consequences of broken confidentiality can effect professional or personal life, can effect professional or personal life, as well as group climate of trustas well as group climate of trust

– Important to get group members to Important to get group members to appreciate importance of this and appreciate importance of this and commit to maintaining confidentiality at commit to maintaining confidentiality at outsetoutset

Outcome Issues in Outcome Issues in Group TherapyGroup Therapy Not studied as extensively as Not studied as extensively as

individual therapyindividual therapy Existing studies strongly suggest Existing studies strongly suggest

that group therapy is beneficialthat group therapy is beneficial– About equal to individual therapy in About equal to individual therapy in

most studies; slightly inferior in a most studies; slightly inferior in a few studies few studies

Can be less expensive than Can be less expensive than individual therapy alsoindividual therapy also

Family Therapy: The Family Therapy: The System as the ProblemSystem as the Problem When the family therapy When the family therapy

movement initially arose in the movement initially arose in the mid-1900s, it was considered mid-1900s, it was considered revolutionary revolutionary – Psychological symptoms were a Psychological symptoms were a

byproduct of dysfunctional familiesbyproduct of dysfunctional families– One individual may exhibit the One individual may exhibit the

symptoms, but the problem actually symptoms, but the problem actually belonged to the entire system belonged to the entire system

Family Therapy: The Family Therapy: The System as the Problem System as the Problem (cont.)(cont.) Circular causality—events influence Circular causality—events influence

each other reciprocallyeach other reciprocally– As opposed to linear causality, which is As opposed to linear causality, which is

endorsed by individual therapistsendorsed by individual therapists Focus on communication patterns in Focus on communication patterns in

familiesfamilies Focus on functionalism of symptomsFocus on functionalism of symptoms

– Within family, symptoms may be Within family, symptoms may be adaptiveadaptive

Family Therapy: The Family Therapy: The System as the Problem System as the Problem (cont.)(cont.) HomeostasisHomeostasis

– Families regulate themselves by Families regulate themselves by returning themselves to an emotional returning themselves to an emotional set pointset point

Like a thermostatLike a thermostat

– A family member may sense that the A family member may sense that the family is reaching an uncomfortable family is reaching an uncomfortable state, and take action (feedback) to state, and take action (feedback) to return it to comfort zonereturn it to comfort zone

Assessment of Assessment of FamiliesFamilies Interviews and other methods as Interviews and other methods as

used in individual therapy are used in individual therapy are commoncommon

GenogramsGenograms– A pencil-and-paper method of creating a A pencil-and-paper method of creating a

family tree that incorporates detailed family tree that incorporates detailed information about the relationships information about the relationships between family members for at least between family members for at least three generations three generations

– Process and result can both be beneficialProcess and result can both be beneficial

Assessment of Assessment of Families (cont.)Families (cont.) Family Life CycleFamily Life Cycle

– A developmental theory for families, A developmental theory for families, including six stagesincluding six stages

Leaving HomeLeaving Home Joining Through MarriageJoining Through Marriage Families with Young ChildrenFamilies with Young Children Families with AdolescentsFamilies with Adolescents Launching Children and Moving OnLaunching Children and Moving On Families in Later LifeFamilies in Later Life

– Can be adapted for diversity in culture, Can be adapted for diversity in culture, experience, and other variablesexperience, and other variables

Assessment of Assessment of Families (cont.)Families (cont.) Identified patientIdentified patient

– It can be critical for the family It can be critical for the family therapist to persuade the family that therapist to persuade the family that the problem is systemic rather than the problem is systemic rather than individual individual

– This can be difficult when the family This can be difficult when the family has attributed the problem entirely has attributed the problem entirely to one member (identified patient)to one member (identified patient)

Discussion QuestionDiscussion Question

What is your opinion of the What is your opinion of the systems approach employed by systems approach employed by family therapists? family therapists?

Can family systems be Can family systems be pathological, or is pathology only pathological, or is pathology only found in individuals?found in individuals?

Family Therapy: Family Therapy: Essential Classic Essential Classic ConceptsConcepts Family StructureFamily Structure

– Unwritten rules by which a family Unwritten rules by which a family operatesoperates

– When flawed, problems in relationships When flawed, problems in relationships and individuals may resultand individuals may result

– Family structure can be improved by Family structure can be improved by focusing on subsystems within families focusing on subsystems within families and the boundaries between themand the boundaries between them

Should be neither enmeshed nor disengagedShould be neither enmeshed nor disengaged

Family Therapy: Family Therapy: Essential Classic Essential Classic Concepts (cont.)Concepts (cont.) Differentiation of SelfDifferentiation of Self

– An appropriate degree of self-An appropriate degree of self-determination, or becoming your determination, or becoming your own person, is essentialown person, is essential

– Families that don’t allow this to Families that don’t allow this to happen can create problems for happen can create problems for their memberstheir members

– Families remain emotionally fused, Families remain emotionally fused, or an undifferentiated ego massor an undifferentiated ego mass

Family Therapy: Family Therapy: Essential Classic Essential Classic Concepts (cont.)Concepts (cont.) TrianglesTriangles

– When two people are in conflict, either one When two people are in conflict, either one may try to bring in a third person to take may try to bring in a third person to take their sidetheir side

– In families, this can be problematic, In families, this can be problematic, especially when the triangulated person is a especially when the triangulated person is a childchild

– Therapeutic goal is to encourage Therapeutic goal is to encourage detriangulation and direct communication detriangulation and direct communication between two people at odds with each other between two people at odds with each other

Family Therapy: Family Therapy: Contemporary Contemporary Approaches Approaches Solution-Focused TherapySolution-Focused Therapy

– Evolved from strategic family therapyEvolved from strategic family therapy– Emphasis on solving problemsEmphasis on solving problems– Emphasis on the use of solution-talk rather Emphasis on the use of solution-talk rather

than problem-talkthan problem-talk Make clients think about positive outcomes rather Make clients think about positive outcomes rather

than unpleasant present situationsthan unpleasant present situations

– Emphasis on exceptions to current problems Emphasis on exceptions to current problems (times when better) and how they created (times when better) and how they created these exceptions (to encourage them to these exceptions (to encourage them to create more exceptions)create more exceptions)

Family Therapy: Family Therapy: Contemporary Contemporary Approaches (cont.)Approaches (cont.) Narrative TherapyNarrative Therapy

– Highlights clients’ tendencies to create Highlights clients’ tendencies to create meanings about themselves and the meanings about themselves and the events in their lives in particular ways events in their lives in particular ways

– Stories we construct about our own lives Stories we construct about our own lives are powerful influences on the way we are powerful influences on the way we experience new eventsexperience new events

We “edit” our experiences to fit the story lineWe “edit” our experiences to fit the story line

– Revise stories and recast selves in more Revise stories and recast selves in more positive, heroic way; new events can be positive, heroic way; new events can be interpreted more positively interpreted more positively

Ethical Issues in Ethical Issues in Family TherapyFamily Therapy Cultural competenceCultural competence

– Family therapists should appreciate the Family therapists should appreciate the cultural background of the familiescultural background of the families

Ethnicity Ethnicity ReligionReligion Other variablesOther variables

– Often, one family includes a blend of Often, one family includes a blend of cultural influencescultural influences

Members from different cultures Members from different cultures Varying levels of acculturationVarying levels of acculturation

Ethical Issues in Ethical Issues in Family Therapy (cont.)Family Therapy (cont.) ConfidentialityConfidentiality

– Can be difficult when one family member Can be difficult when one family member tells therapist something in privatetells therapist something in private

Diagnostic AccuracyDiagnostic Accuracy– DSM disorders apply to individuals, not DSM disorders apply to individuals, not

familiesfamilies– If diagnosis is required, therapist who thinks If diagnosis is required, therapist who thinks

system is flawed has a dilemma system is flawed has a dilemma Labeling identified patient with disorder can Labeling identified patient with disorder can

perpetuate the family’s tendency to blame one perpetuate the family’s tendency to blame one membermember

Outcome Issues in Outcome Issues in Family TherapyFamily Therapy Methodological difficulties in Methodological difficulties in

measuring outcome of family measuring outcome of family therapy include the issue of which therapy include the issue of which family members’ opinions should be family members’ opinions should be solicitedsolicited

Not as much outcome research as Not as much outcome research as individual therapy, but existing individual therapy, but existing research is very positiveresearch is very positive– Family therapy appears to work about Family therapy appears to work about

as well as other modes of therapy as well as other modes of therapy

Discussion QuestionDiscussion Question

As a family therapist, would you allow members As a family therapist, would you allow members of a family which you are treating to schedule of a family which you are treating to schedule individual appointments in addition to family individual appointments in addition to family sessions? If so, would information disclosed sessions? If so, would information disclosed during individual sessions remain undisclosed to during individual sessions remain undisclosed to other family members, or would all information other family members, or would all information shared by each family member be communicated shared by each family member be communicated to all others? to all others?

What other difficult interpersonal dynamics might What other difficult interpersonal dynamics might arise in family therapy? What are some ways in arise in family therapy? What are some ways in which a family therapist can address these which a family therapist can address these issues?issues?

Questions?Questions?